Chapter 180: Phimosis Reduction

INTRODUCTION

A phimosis is a condition in which the foreskin cannot be retracted proximally to the glans penis.^1-18 The presence of a phimosis can interfere with cleaning under the foreskin, allows the accumulation of secretions and debris (i.e., smegma), and may predispose the patient to infections and possible malignancy.¹⁸ It is classified into two subgroups as physiologic and pathologic. Physiologic phimoses occur naturally in newborns. In males younger than 4 years of age, it is normal for the foreskin not to be retractable and it should not be forcibly retracted.¹⁹ In older boys and adults, the foreskin can usually be retracted without difficulty.¹ A pathologic phimosis is the inability to retract the foreskin after it was previously retractable or after puberty, usually secondary to scarring of the foreskin (Figure 180-1).^20,21 Surgical treatment for a phimosis has been known for hundreds of years.² A Byzantine surgeon by the name of Oribasius, in the fourth century AD, gave a seemingly well-acquainted description of a technique involving forced dilation of the constrictive foreskin, scalloping out of its inner surface, then stretching it over a parchment-wrapped lead tube placed between the filleted skin and the glans.² Current techniques for the management of a phimosis in the Emergency Department are simple and remain an important intervention directed at relieving urinary obstruction.

ANATOMY AND PATHOPHYSIOLOGY

At birth there is a physiologic phimosis in the majority of male neonates. This is due to natural adhesions that exist between the foreskin and the glans of the penis. During the first 3 to 4 years of life, the penis grows and epithelial debris (i.e., smegma) accumulates under the foreskin. The debris gradually separates the foreskin from the glans. Intermittent penile erections aid in allowing the foreskin to eventually become retractable. The foreskin of most males will retract easily by the age of 4. Forcible retraction should be categorically discouraged as this can result in scarring and constriction.¹ Parents may report that the foreskin bulges during urination which is a normal finding with phimosis. For a nonobstructive phimosis in children, 4 to 6 weeks of topical steroids applied from the tip of the foreskin to the corona of the glans penis have shown excellent results in releasing the stubborn physiologic adhesions between the foreskin and the glans.^3,4,22,23

A phimosis can be the cause or the effect of other medical conditions (Figure 180-1).²⁴ Recurrent infections (e.g., balanitis or balanoposthitis), repeated urinary catheterization, forceful foreskin retraction, and poor hygiene can lead to scarring of preputial orifices causing a pathologic phimosis. A pathologic phimosis may arise in diabetics due to the presence of glucose in their urine, giving ...